Patients with Supratentorial Aneurysmal Subarachnoid Hemorrhage During the Intermediate Period: Waiting or Actively Treating

Perhaps the most difficult practical decision for neurosurgeons these days is whether to secure aneurysms during the intermediate period (4–10 days) after aneurysmal subarachnoid hemorrhage (SAH). We reviewed retrospectively a series of 115 patients with a Hunt–Hess grade I–III upon admission who were admitted 4–10 days after initial supratentorial aneurysmal SAH. Patients who underwent active treatment in the intermediate period were assigned to the intermediate group (n = 49), while those who accepted delayed obliteration of a ruptured aneurysm (11–30 days) were assigned to the late group (n = 66). The demographic characteristics, size and site of aneurysms, and clinical conditions were well balanced in the two groups. There was no difference in outcome between the two groups according to the Glasgow Outcome Scale (GOS) at discharge or a 6-month follow-up. Rebleeding before aneurysms obliteration was the leading factor resulting in poor outcome. In conclusion, for patients with supratentorial aneurysmal SAH who were in good clinical condition upon admission, active treatment during the intermediate period offered a good chance for a favorable outcome. An even larger number of patients from randomized clinical trials might be necessary to draw more reliable conclusions.     

Distribution of Hematocrit Values After Aneurysmal Subarachnoid Hemorrhage

Low hematocrit values are common after subarachnoid hemorrhage and may be associated with elevated cerebral blood flow and transcranial Doppler ultrasound (TCD) velocities, which may confound the interpretation of velocity as an indicator of vasospasm. The exact distribution of hematocrit among a neurosurgical population would be useful in assessing the magnitude of this difficulty but has not been previously reported. A database containing hematocrit values recorded at TCD examinations over a period of 7 years was reviewed. Two thousand four hundred thirteen hematocrit values were recorded for 575 patients. The distribution of hematocrit values was recorded among patients and among TCD studies. Eighteen percent of the patient population achieved a hematocrit of 26% or less at some point in their hospital stay, whereas 57% of patients achieved a hematocrit of 30% or less. Six percent of the TCD studies were associated with a hematocrit of 26% or less, while 33% of the studies were associated with a hematocrit of 30% or less.     

动脉瘤性蛛网膜下腔出血后慢性脑积水

目的探讨动脉瘤性蛛网膜下腔出血后(aSAH)慢性脑积水的发生率及其易患因素。方法回顾性研究2003年1月至2005年9月我科aSAH病例221例,采用单因素及多因素统计方法分析与慢性脑积水发生的相关影响因素。结果慢性脑积水的发生率为12.7%(28/221)。经单因素分析显示,患者年龄、Hunt-Hess级别、Fisher级别、前交通动脉瘤、aSAH次数以及脑室内出血具有统计学意义;多因素logistic回归分析显示,Fisher级别、脑室内出血、aSAH次数、前交通动脉瘤具有统计学意义。结论慢性脑积水为aSAH后一较常见并发症,影响其发生的高危因素包括Fisher级别、脑室内出血、aSAH次数、前交通动脉瘤。对具上述危险因素的aSAH患者应注意跟踪随访,及时诊治。     

动脉瘤性蛛网膜下腔出血后认知功能障碍的特点

动脉瘤性蛛网膜下腔出血患者虽然大多可以达到临床上的“完全康复”,但部分该类患者却遗留长期的认知功能障碍,程度较轻微,临床不易察觉,可使用神经心理学量表及神经电生理检查对认知功能进行全面检测。目前认为认知功能障碍的严重程度及发生机制可能与蛛网膜下腔出血和早期脑损伤有关。本文对动脉瘤性蛛网膜下腔出血后认知功能障碍的危险因素、可能的机制做一阐述,以期指导临床。     

经侧脑室短期重复应用重组链激酶预防动脉瘤破裂后迟发性脑血管痉挛

目的 :观察经侧脑室短期重复应用重组链激酶 (r SK)并引流脑脊液 ,对预防脑动脉瘤破裂蛛网膜下隙出血 (SAH)后迟发性脑血管痉挛 (DCV)的效果。方法 :14例脑动脉瘤破裂Fisher 3级患者 ,于 72h内行瘤颈夹闭或瘤体介入栓塞术 ,以及侧脑室外引流后 ,分为治疗组和对照组 ,各 7例。治疗组经侧脑室注入r SK 5mg·d-1,连续 2～ 3d。术后出现迟发性神经功能损害者诊断为DCV ;术后 1～ 3个月以GOS评估预后。结果 :治疗组术后SAH血凝块 3～ 4d消失 ,无DCV发生 ,GOS均为 5分。对照组术后 4～ 10d血凝块消失 ,3例无DCV发生 ,GOS为 5分 ;4例DCV者 ,2例GOS为 4分、3分和 1分各 1例。结论 :经侧脑室短期重复应用r SK ,对防治SAH后DCV有较好的疗效。     

Effect of Cisternal Drainage on the Shunt Dependency Following Aneurysmal Subarachnoid Hemorrhage

Objective

Shunt-dependent chronic hydrocephalus (SDCH) is known to be a major complication associated with aneurysmal subarachnoid hemorrhage (aSAH). Old age is known to be one of numerous factors related to the development of SDCH. This study investigated whether postoperative cisternal drainage affects the incidence of SDCH and clinical outcome in elderly patients with aSAH.

Methods

Fifty-nine patients participated in this study. All patients underwent aneurysmal clipping with cisternal cerebrospinal fluid (CSF) drainage. Clinical variables relevant to the study included age, sex, location of ruptured aneurysm, CT finding and clinical state on admission, clinical outcome, and CSF drainage. We first divided patients into two groups according to age (<70 years of age and ≥70 years of age) and compared the two groups. Secondly, we analyzed variables to find factors associated with SDCH in both groups (<70 years of age and ≥70 years of age).

Results

Of 59 patients, SDCH was observed in 20 patients (33.9 %), who underwent shunt placement for treatment of hydrocephalus. Forty seven percent of cases of acute hydrocephalus developed SDCH. In the elderly group (≥70 years of age), the duration and amount of CSF drainage did not affect the development of chronic hydrocephalus.

Conclusion

In elderly patients, although the incidence of SDCH was significantly higher, clinical outcome was acceptable. The duration and the amount of cisternal drainage did not seem to be related to subsequent development of chronic hydrocephalus within elderly patients aged 70 or older.     

动脉瘤性SAH迟发性脑血管痉挛的多元因素分析

目的 探讨动脉瘤性蛛网膜下腔出血（SAH）继发脑血管痉挛的相关因素。方法 回顾性分析本院收治的54例动脉瘤性SAH病人的临床资料，判定脑血管痉挛程度，统计分析其相关因素。结果Fisher分级Ⅲ-Ⅳ级患者脑血管痉挛发生率（7014％，19／27）明显高于Fisher分级Ⅰ-Ⅱ级者（4414％，12／27）（P〈0．01）；Hunt—Hess分级Ⅲ-Ⅴ级患者脑血管痉挛发生率（75．0％，21／28）明显高于Hunt—Hess分级Ⅰ-Ⅱ级者（38．5％，10／26）（P〈0．05）；3d后手术患者的脑血管痉挛发生率（70．0％，21／30）明显高于3d内手术患者（41．7％，10／24）（P〈0．05）。结论SAH的Fisher分级〉Ⅱ级和Hunt—Hess分级〉Ⅱ级是颅内动脉瘤继发脑血管痉挛的危险因素。早期手术能降低脑血管痉挛的发生率。     

远隔缺血适应干预对动脉瘤性蛛网膜下腔出血患者凝血功能的影响

目的 探讨远隔缺血适应（remote ischemic conditioning,RIC）对动脉瘤性蛛网膜下腔出血患者凝血功能的影响。      

Metaanalysis of Tirilazad Mesylate in Patients with Aneurysmal Subarachnoid Hemorrhage

Background  Tirilazad is a non-glucocorticoid, 21-aminosteriod that inhibits lipid peroxidation. It had neuroprotective effects in experimental ischemic stroke and reduced angiographic vasospasm after experimental subarachnoid hemorrhage (SAH). Five randomized clinical trials of tirilazad were conducted in patients with SAH. We performed a meta-analysis of these trials to assess the effect of tirilazad on unfavorable outcome, symptomatic vasospasm, and cerebral infarction after SAH. Methods  Data from 3,797 patients were analyzed and modeled using random effect and Mantel-Haenszel meta-analyses and multivariable logistic regression to determine the effect of tirilazad on clinical outcome, symptomatic vasospasm, and cerebral infarction. Clinical outcome was assessed 3 months after SAH using the Glasgow outcome scale, and symptomatic vasospasm was defined by clinical criteria with laboratory and radiological exclusion of other causes of neurological deterioration. Results  The five trials were randomized, double-blind, and placebo-controlled. Tirilazad did not significantly decrease unfavorable clinical outcome on the GOS (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.89–1.20) or cerebral infarction (OR 1.04, 95% CI 0.89–1.22). There was a significant reduction in symptomatic vasospasm in patients treated with tirilazad (OR 0.80, 95% CI 0.69–0.93). There was no heterogeneity across the five trials. Conclusion  Tirilazad had no effect on clinical outcome but did decrease symptomatic vasospasm in five trials of aneurysmal SAH. The dissociation between clinical outcome and symptomatic vasospasm deserves further investigation.     

神经炎症在动脉瘤性蛛网膜下腔出血后早期脑损伤中的作用

早期脑损伤(early brain injury,EBI)是影响动脉瘤性蛛网膜下腔出血(aneurysmal subarachnoid hemorrhage,aSAH)患者预后的重要因素之一.目前aSAH后EBI产生机制尚不明确,神经炎症可能为其主要驱动因素,其作用机制包括:红细胞降解产物和激活的小胶质细胞诱导神经炎症...     

颅内破裂动脉瘤手术时机的探讨(附237例分析)

目的探讨颅内破裂动脉瘤手术时机与临床预后的关系。方法回顾性分析2005年我院收治的237例颅内破裂动脉瘤，其中196例行手术治疗。按入院时Hunt—Hess分级将手术病人分为A组（Ⅰ～Ⅲ级）162例，B组（Ⅳ、Ⅴ级）34例；根据手术时间分为早期手术组（SAH3d内手术）19例，延期手术组（SAH4～10d手术）82例，晚期手术组（SAH11d之后手术）95例。比较不同手术期别动脉瘤术中破裂率、术后1个月GOS评分及术后主要并发症（脑血管痉挛、脑积水）发生率，并进行统计学分析。结果24例（10．1％）因再出血丧失治疗机会。术中动脉瘤破裂早期手术组3例（15，8％），延期手术组8例（9．8％），晚期手术组6例（613％）。术后脑血管痉挛发生率早期手术组为15，8％，延期手术组为19，5％，晚期手术组为17，9％。脑积水发生率以晚期手术组最高（14，7％）。对术后1个月GOS评分Ridit分析结果显示：A、B两组中均以早期手术组治疗效果最佳．延期手术次之．晚期手术最差。结论早期手术可规避颅内破裂动脉瘤再出血的风险，降低主要并发症发生率。对于各个级别（包括Ⅳ、Ⅴ级）的SAH病人，均应根据治疗者的手术经验与技巧和所在医院的条件，及早诊断，尽早手术。     

Calcium Homeostasis During Magnesium Treatment in Aneurysmal Subarachnoid Hemorrhage

Objective  Magnesium treatment in patients with subarachnoid hemorrhage (SAH) can result in hypocalcemia; this hypocalcemia increases the risk of delayed cerebral ischemia (DCI) and poor outcome. We assessed whether low serum levels of total calcium in patients with SAH treated with magnesium is mediated by parathyroid hormone (PTH) or calcitriol, and whether increased PTH or low serum levels of ionized calcium are associated with an increased risk of DCI and poor outcome. Patients and Methods  We studied 167 patients included in a randomized, placebo controlled trial on magnesium in SAH. Mean serum magnesium during treatment was related to mean serum levels of ionized calcium, PTH and calcitriol with linear regression. Hypocalcemia (Ca²⁺) and high serum PTH were related to the occurrence of DCI by means of the Cox proportional hazards model and to poor outcome by logistic regression. Results  Serum magnesium was inversely related to ionized calcium (B = −0.1; 95% CI −0.12 to −0.06), but not to PTH or calcitriol. Neither hypocalcemia nor high serum PTH was related to DCI. Hypocalcemia did not increased the risk for poor outcome (OR 1.2; 95% CI 0.6–2.3). In the subgroup of patients with known PTH (n = 67), high serum PTH increased the risk for poor outcome (OR 5.4; 1.6–18.9). Conclusions  Magnesium treatment in patients with SAH leads to hypocalcemia without effect on outcome. PTH is related to poor outcome, but this is independent of magnesium therapy.     

高压氧联合康复治疗动脉瘤性蛛网膜下腔出血术后患者6个月预后影响因素分析

目的 探讨高压氧联合康复治疗动脉瘤性蛛网膜下腔出血术后患者6个月预后的影响因素。
方法 回顾性纳入2014年10月-2019年6月首都医科大学附属复兴医院康复中心连续收治的动脉瘤
性蛛网膜下腔出血术后患者，均接受高压氧联合康复治疗至出院。收集患者临床资料，良好预后定
义为术后6个月mRS评分0～3分。采用多因素Logistic回归分析影响6个月临床预后的相关因素。
结果 共纳入68例患者，平均年龄57.0±11.6岁，男性33例（48.5%）。6个月良好预后率为51.5%
（35/68）。多因素Logistic回归分析显示，入院NIHSS评分（OR 2.131，95%CI 1.532～2.876）和迟发性脑
缺血（OR 1.743，95%CI 1.203～2.145）为不良预后的独立影响因素。
结论 高压氧联合康复治疗的动脉瘤性蛛网膜下腔出血术后患者中，康复治疗前严重的神经功能
缺损及迟发性脑缺血与其6个月不良预后相关。     

高压氧联合康复治疗动脉瘤性蛛网膜下腔出血术后患者6个月预后影响因素分析

目的 探讨高压氧联合康复治疗动脉瘤性蛛网膜下腔出血术后患者6个月预后的影响因素。方法 回顾性纳入2014年10月-2019年6月首都医科大学附属复兴医院康复中心连续收治的动脉瘤性蛛网膜下腔出血术后患者,均接受高压氧联合康复治疗至出院。收集患者临床资料,良好预后定义为术后6个月mRS评分0～3分。采用多因素Logistic回归分析影响6个月临床预后的相关因素。结果 共纳入68例患者,平均年龄57.0±11.6岁,男性33例（48.5%）。6个月良好预后率为51.5%（35/68）。多因素Logistic回归分析显示,入院NIHSS评分（OR 2.131,95%CI 1.532～2.876）和迟发性脑缺血（OR 1.743,95%CI 1.203～2.145）为不良预后的独立影响因素。结论 高压氧联合康复治疗的动脉瘤性蛛网膜下腔出血术后患者中,康复治疗前严重的神经功能缺损及迟发性脑缺血与其6个月不良预后相关。     

Fluid Balance and Blood Volume Measurement after Aneurysmal Subarachnoid Hemorrhage

Background  Patients with aneurysmal subarachnoid hemorrhage (SAH) are at risk for circulatory volume depletion, which is a risk factor for delayed cerebral ischemia (DCI). In a prospective observational study we assessed the effectiveness of fluid administration based on regular evaluation of the fluid balance in maintaining normovolemia. Methods  A total of 50 patients with aneurysmal SAH were included and were treated according to a standard protocol aimed at maintaining normovolemia. Fluid intake was adjusted on the basis of the fluid balance, which was calculated at 6-h intervals. Circulating blood volume (CBV) was measured by means of pulse dye densitometry (PDD) on alternating days during the first 2 weeks after SAH. Results  Of the 265 CBV measurements, 138 (52%) were in the normovolemic range of 60–80 ml/kg; 76 (29%) indicated hypovolemia with CBV < 60 ml/kg; and 51 (19%) indicated hypervolemia with CBV > 80 ml/kg. There was no association between CBV and daily fluid balance (regression coefficient β = −0.32; 95% CI: −1.81 to 1.17) or between CBV and a cumulative fluid balance, adjusted for insensible loss through perspiration and respiration (β = 0.20; 95% CI: −0.31 to 0.72). Conclusion  Calculations of fluid balance do not provide adequate information on actual CBV after SAH, as measured by PDD. This raises doubt whether fluid management guided by fluid balances is effective in maintaining normovolemia.